https://doi.org/10.47108/jidhealth.Vol5.Iss2.223 Yahyaa BT, et al., Journal of Ideas in Health 2022;5(2):673-678 © The Author(s). 2022 This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author (s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (https://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. e ISSN: 2645-9248 Journal homepage: www.jidhealth.com Open Access knowledge and attitude of Iraqi women in reproductive age group about risk factors in pregnancy Badeaa Thamer Yahyaa1*, Mahasin Ali Altaha1, Ru’ya Abdulhadi Al-Rawi1, Mustafa Ali Mustafa Al- Samarrai1, Saad Ahmed Ali Jadoo2 Abstract Improved knowledge among women about maternal risk factors significantly reduced the likelihood of adverse events in pregnancy and childbirth. This study aimed to explore Iraqi women's knowledge and attitudes about maternal risk factors in pregnancy. A multicenter cross-sectional survey was conducted from 01 January to 31 March 2019 among women of the reproductive age (15-49 years). A convenient sampling technique using a semi-structured questionnaire was recruited to interview the sample. SPSS version 16.0 was used to analyze the data. Descriptive and inferential statistics (Chi-square test) were used to present data with the significance level considered at <0.05. Data of 250 women underwent final analysis. The mean age of respondents was 27.76 (±6.3 years). Most of the respondents (79.9%) correctly knew the maternal risk factors in pregnancy. A large percentage of women knew that poor nutrition, anemia (95.6%), smoking and passive smoke (95.6%), and obesity (85.2%) during pregnancy are risk factors affecting the fetus’ health. However, about 40.0% of women thought there was no harm during pregnancy, and therefore there was no need for medical check-ups regularly. In bivariate analysis, there was a significant association between knowledge and level of education. The higher the level of education, the greater the women's knowledge about risk factors such as malnutrition and anemia (P=<0.001), obesity (P=0.04), diabetes (P=0.002), repeated urinary tract infection (P=0.017), Rh incompatibility (<0.001), history of previous cesarean section (P=0.010), smoking and passive smoking (P=0.014) and evidence of bleeding (P=0.001). In conclusion, Iraqi pregnant women demonstrated a good level of knowledge about the risk factors during the pregnancy. Keywords: Knowledge, Attitude, Reproductive Age, Risk Factors, Pregnancy, Women, AL-Falluja, Iraq Background Undoubtedly, increased knowledge among women about risk factors during pregnancy reduces mortality and morbidity among mothers and children. Pregnancy is an excellent opportunity to adopt a healthy lifestyle that can benefit mothers and newborns. Age is one of the most important determinants and risk factors for pregnancy. Teens under 15 are at high risk of gestational complications such as preeclampsia, anemia, premature delivery, low birth weight, and congenital fetal anomalies [1]. On the other hand, pregnancy over the age of 35 is associated with worse outcomes and is treated as a high-risk pregnancy due to the potential for a higher rate of chronic. Medical conditions. Combined age-related factors, such as reduced fertility, genetic risks, miscarriage, and stillbirth, can make it more difficult for a woman to get pregnant [2]. Adequate nutrition is a fundamental cornerstone of any individual's health, especially critical for pregnant women because inadequate nutrition affects women's health and their children's health. Children of malnourished women are more likely to face cognitive impairments, short stature, lower resistance to infections, and a higher risk of disease and death [3,4]. According to the World Health Organization, many women do not get enough micronutrients in their diets during reproductive age and pregnancy, contributing to about one-third of all child deaths and impairing their development [5]. Moreover, the significant consequence of nutritional insufficiency is obesity. During pregnancy, there are many complications associated with obesity, such as first and third- trimester miscarriage, preeclampsia, gestational diabetes, failure ___________________________________________________ med.badeaa.thamir@uoanbar.edu.iq 1Department of Family and Community Medicine, Faculty of Medicine, Anbar University, Anbar, Iraq. A full list of author information is available at the end of the article. https://doi.org/10.47108/jidhealth.Vol5.Iss2.223 http://www.jidhealth.com/ Yahyaa BT, et al., Journal of Ideas in Health (2022); 5(2):673-678 674 to induce labor, and increased rates of cesarean sections [6]. Over the last few decades, high blood pressure in pregnancy steadily increased. Bateman et al. [7] reported that "1 in every 12 to 17 pregnancies" in the US develop high blood pressure between 20 to 44 years old. Daviglus et al. [8] found that the prevalence is higher in rural areas, especially among the females in the reproductive age group. Although high blood pressure is preventable and treatable during pregnancy, inappropriate diagnosis and treatment bear high risk for mothers and babies such as preeclampsia, eclampsia, stroke, and preterm delivery [9]. High blood sugar develops during pregnancy is called “Gestational diabetes”. Fortunately, it normally disappears after birth. The likelihood of having problems is significantly reduced when properly controlling the blood sugar levels. High blood sugar in the first weeks of pregnancy- associated birth defects, an increased risk of miscarriage, a high rate of cesarean sections, and postpartum complications. Babies born to a woman with gestational diabetes are often much larger, a condition called ‘Giantism’ [10]. Pregnant women experience many hormonal and mechanical changes that enhance urinary stasis and vesicoureteral reflux. Urinary tract infection (UTI) is associated with pyelonephritis, preterm labor, low birth weight, and an increased risk of perinatal mortality [11]. Having an Rh-negative blood type requires special attention during each pregnancy. Historically, Rh-negative women were often at risk for miscarriage in the second or third trimester. It has become rare as pregnant Rh- negative women are routinely given the RhoGAM injection to lessen this risk [12]. Most women take some kind of drug or medication without realizing the potential for harm. Some of these substances may cross the placenta and reach the developing fetus. The possible effects may include developmental delay “erotogenic”, intellectual disability, birth defects, miscarriage, and stillbirth, and the potential harm depends on the amount and frequency of use [13]. Undergoing several abortions or enduring more than one miscarriage increase is the risk of problematic subsequent pregnancies. These women face higher chances of vaginal bleeding, preterm birth, low birth weight, and placenta complications [14]. Smoking during pregnancy can lead to probable complications later on, so it is sensible to completely avoid any kind of exposure to smoking or passive smoking to reduce the worse consequences such as newborn low birth weight, congenital disabilities, premature labor, miscarriage, and sudden infant death syndrome [15]. This study aimed to determine the knowledge and attitude of women in the reproductive age group regarding the risk factors associated with pregnancy. Methods Study design A cross-sectional multicenter interview-based survey was conducted from 01 January to 31 March 2019. A convenient sample technique was used to collect the data from the outpatient gynecological services of four health centers located in Al-Falluja and Baghdad, Iraq. We conducted the research following the Declaration of Helsinki. The author conducted the research following the Declaration of Helsinki. The study's protocol was approved by the Ethics committee of the Faculty of Medicine, University of Anbar, 2019. Moreover, informed consent was obtained from each participant after explaining the study objectives and the guarantee of secrecy. Inclusion and exclusion criteria All the Iraqi pregnant women of the reproductive age (15-49) and willing to participate have been included. Women aged out of the reproductive life, unable to answer the questionnaire, and not willing to participate have been excluded from the study. Sample size According to a local study conducted by Al Abedi GA et al. [16], the knowledge of pregnant women about the risk of pregnancy in Iraq was 42.0% in 2019. The sample size calculator arrived at 257 participants, using a margin of error of ±6.0%, a confidence level of 95%, and a 42.0% response distribution. Study instrument and data collection A semi-structured questionnaire was developed to interview the participants. The questionnaire was divided into three sections: First Sections: Socio-demographic data including age, marital status, occupation, level of education, number of children, number of abortions, and number of dead children. For analysis, the education variable was categorized as either “mild education” for illiterate women, “moderate education” for those who can read and write or in the primary and Intermediate school, and “high education” for those who were in secondary school or undergraduate level. Second Sections: Twelve close-ended questions to assess the knowledge of women about pregnancy-related risk factors such as the effect of nutritional state, obesity, hypertension, diabetes Miletus, urinary tract infection, ABO and Rh system blood group, non-prescribed drugs, and smoking. Third Section: Five closed-ended questions to assess a woman’s attitude towards pregnancy, such as harm caused by pregnancy, regular check-ups with doctors, and attention to doctors’ advice regarding nutrition and pregnancy planning. Statistical analysis The univariate analysis is presented in the form of mean, standard deviation (SD), and percentage. Bivariate analysis using the Chi-square test was performed to evaluate the association between the women’s knowledge (Yes and No) and the education level of respondents (Mild, Moderate, and High). A P-value of ≤ 0.05 was considered statistically significant. The statistical analysis was carried out by using SPSS 16. Results Socio-demographic, obstetrics, and gynecology characteristics Out of 257 respondents, the data of 250 respondents have undergone the final analysis. Women were of the reproductive age (15-49) with a mean age of 27.76 ± 6.3 years. Most of the respondents (21.6%) in the age group (30-34 years) were married (96.8%), highly educated (34.0%), housewives (83.2%), and primiparous women (22.4%). About 21.2% experienced abortion, and 9.2% had a child death (Table 1). Yahyaa BT, et al., Journal of Ideas in Health (2022); 5(2):673-678 675 Table 1: Socio-demographic, obstetrics, and gynecology characteristics of the study sample (N=250) Variables Categories N % Age (years) Mean ± SD 27.76 ± 6.3 <20 years 18 7.2 20 – 24 years 70 28 25 – 29 years 75 30 30 – 34 years 54 21.6 35 – 39 years 14 5.6 40 years and above 19 7.6 Social status of women Married 242 96.8 Widow 7 2.8 divorced 1 0.4 Education of women Illiterate 18 7.2 Read & write 24 9.6 Primary 33 13.2 Intermediate 50 20 Secondary 40 16 University 85 34 Occupation of women Housewife 208 83.2 Employed 42 16.8 Parity (0) 68 27.2 1 56 22.4 2 51 20.4 3 39 15.6 4 18 7.2 5+ 18 7.2 Abortion 53 21.2 Child deaths 23 9.2 The knowledge regarding risk factors in pregnancy A high percentage (79.9%) of women showed good knowledge of pregnancy-related risk factors. About half of them (50.6%) knew that the pregnancy at the age above the 35years causes congenital anomalies, compared to 73.2% of them who knew that pregnancy at age 15 or younger puts the life of the mother and fetus at risk and the possibility of a cesarean section. Most mothers knew the leading risk factor during pregnancy. More than ninety percent agreed that malnutrition (95.6%) causes preterm labor, smoking (95.6%) is harmful to the health of the fetus, and those who experienced previous abortion or cesarean section (90.8%) are more likely to need frequent doctor visits. More than eighty percent of mothers knew using drugs not prescribed by the doctor during pregnancy may cause fetus malformations (89.2%), obesity (85.2%) may cause complications during pregnancy, bleeding at the beginning or during pregnancy may cause abortion (86.0%) and, the repeated urinary tract infection during pregnancy is a risk factor (82.0%). More than seventy percent of mothers knew that high blood pressure during pregnancy could cause maternal death (76.0%), and parents' Rh-group incompatibility (70.8%) may expose the fetus to fall or deformation. About 63.9% know that diabetes can cause miscarriage (Table 2). Table 2: Women’s knowledge about risk factors during pregnancy (n=250) No. Questions Categories No. % 1. Pregnancy with an age greater than 35 years may lead to fetal abnormalities. Yes 127 50.8 No 123 49.2 2. The malnutrition and anemia of the pregnant woman result in low birth weight or premature birth. Yes 239 95.6 No 11 4.4 3. High blood pressure during pregnancy can cause maternal death. Yes 190 76.0 No 60 24.0 4. Obesity in the pregnant mother may cause complications during pregnancy. Yes 213 85.2 No 37 14.8 5. Diabetes during pregnancy may cause miscarriage or the birth of a large-weight child. Yes 159 63.6 No 91 36.4 6. Pregnancy at the age of 15 or less presents the life of the mother and fetus at risk and the probability of a cesarean section. Yes 183 73.2 No 67 26.8 7 Repeated urinary tract infection during pregnancy or swollen feet is a risk factor for pregnancy. Yes 205 82.0 No 45 18.0 8 If the mother's blood type is negative and the father is cheerful (Rh incompatibility), the fetus is exposed to fall or deformation. Yes 177 70.8 No 73 29.2 9 The doctor's use of drugs not prescribed during pregnancy presents the fetus with malformations. Yes 223 89.2 No 27 10.8 10 If the mother has projections or a previous cesarean section, she needs frequent doctor reviews. Yes 227 90.8 No 23 9.2 Yahyaa BT, et al., Journal of Ideas in Health (2022); 5(2):673-678 676 11 Smoking and passive smoking are harmful to fetal health. Yes 239 95.6 No 11 4.4 12 Any bleeding at the beginning or during pregnancy is a risk factor. Yes 215 86.0 No 35 14 Women’s attitude towards some risk factors during pregnancy The women’s attitudes toward some risk factors during pregnancy showed that about forty percent agreed that they do not find harm in pregnancy every year and thought it was unnecessary to regularly visit the doctor or health care center when the pregnancy is normal. A large proportion (92.0%) of women agreed to visit the doctor immediately if they had bleeding during pregnancy. Moreover, eighty-eight percent agreed that pregnant women should follow the doctor’s advice on nutrition during pregnancy. About two- thirds of pregnant women agreed on four or fewer children (Table 3). Table 3: Attitude of women towards some risks with pregnancy (n = 250) Questions Categories N % Do not find harm in pregnancy every year. Agree 101 40.4 Disagree 149 59.6 I do not think it is necessary to check the doctor or care regularly when my pregnancy is normal. Agree 103 41.2 Disagree 147 58.8 Follow the doctor's advice on nutrition during pregnancy. Agree 221 88.4 Disagree 29 11.6 See your doctor immediately if you have bleeding during pregnancy. Agree 230 92.0 Disagree 20 8.0 Have four or fewer children. Agree 196 67.6 Disagree 81 32.4 Association between women’s knowledge and the educational level Bivariate analysis showed a significant association between knowledge and level of education. The high educated women have significantly more knowledge than the mild and moderate educated women in terms of knowing the impact of malnutrition and anemia (p<0.001), obesity (P=0.039), diabetes mellitus (P=0.002), repeated urinary tract infection(P=0.017), parents’ Rh incompatibility (P=<0.001), history of previous cesarean section (P=0.010), and bleeding during pregnancy (P=0.014), respectively (Table 4). Table 4: Association between women's knowledge about risk factors in pregnancy and the educational level (n=250) Questions Knowledge Mild N(%) Moderate N(%) High N(%) *p-value Age of pregnant women ˃35 years Yes 34(13.6) 47(18.8) 46(18.4) 0.274 No 4(16.4) 43(17.2) 39(15.6) Malnutrition and anemia during pregnancy Yes 66(26.4) 88(35.2) 85(34.0) <0.001 No 9(3.6) 2(0.8) 0(0.0) Obesity of the pregnant mother Yes 38(15.2) 85(34.0) 90(36.0) 0.039 No 10(0.4) 18(7.2) 9(3.6) Diabetes mellitus during pregnancy Yes 19(7.6) 90(36.0) 50(20.0) 0.002 No 40(16.0) 21(8.4) 30(12.0) Age of pregnant women 15 years or less Yes 83(33.2) 45(18.0) 55(22.0) 0.180 No 34(13.6) 20(8.0) 13(5.2) Repeated urinary tract infection during pregnancy Yes 65(26.0) 50(20.0) 90(36.0) 0.017 No 25(10.0) 5(2.0) 15(6.0) Parents’ Rh incompatibility Yes 75(30.0) 80(32.0) 22(8.8) <0.001 No 25(10.0) 18(7.2) 30(12.0) Using drugs not prescribed by the doctor during pregnancy Yes 73(29.2) 100(40) 50(20.0) 0.768 No 12(4.8) 7(2.8) 8(3.2) Mothers have a previous cesarean section. Yes 88(35.2) 44(17.6) 95(38.0) 0.010 No 16(6.4) 2(0.8) 5(2.0) Smoking and passive smoking Yes 95(38.8) 89(35.6) 60(24.0) 0.014 No 6(2.4) 5(2.0) 0(0.0) Bleeding at the beginning or during pregnancy Yes 35(14.0) 89(35.6) 91(36.4) No 15(6.0) 11(4.4) 9(3.6) Yahyaa BT, et al., Journal of Ideas in Health (2022); 5(2):673-678 677 Discussion In this study, we tried to assess the knowledge and attitude of Iraq women toward pregnancy-related risk factors. Our target population was the pregnant women of the reproductive age (15-49 years) attending four outpatient clinics in AL-Falluja and Baghdad city. Most of our respondents (30.0%) were in the age group (25-29 years), and 7.6% were aged 40 and above, which is lower than that reported by Espansito et al. [17] and Mastroiacvone et al. [18]. Moreover, the percentage of highly educated women was higher than that reported by earlier studies from Nepal [19] and Sudan [20]. However, most of our respondents were housewives (83.2%) because of fewer chances for employment in Iraq [4], especially among the families exposed to internal displacement [21,22]. Most of the respondents were multiparous women. A similar finding was reported in a previous study in Iraq, confirming that the average Iraqi family is seven members [23]. In this study, most respondents had good knowledge (79.9%) about the main risk factors in pregnancy. Indeed, the findings showed that most surveyed samples knew that malnutrition, obesity, smoking, diabetes, and bleeding were pregnancy-related risk factors. Similarly, findings were reported in other studies in Italy [24] and the USA [25], indicating that smoking is the risk factor affecting pregnancy. Shub et al. [26] found that pregnant women have adequate knowledge about the association of obesity with pregnancy complications [26]. Regarding knowledge of women about risk factors in pregnancy, almost 96.5% of all respondents knew malnutrition and anemia in pregnant women might lead to low birth weight or premature birth. Our results were higher than those reported by Eni- olorunda et al. [27] in Nigeria (36.7%) but lower than that reported by Ghimire and Pande (98.0%) [19]. Likewise, to the finding reported by Mahejabin et al. [28] in Bangladesh, our respondents showed excellent knowledge that a mother who has a history of abortion and cesarean section should do frequent doctor's visits for antenatal care. Moreover, Uzun et al. [29] indicated that fear is one of the important motives behind the woman's desire to undergo tests. A large percentage of women knew that using a drug during pregnancy without a doctor's advice and pregnancy with age greater than 35 years might lead to fetus malformation (89.6%) compared to findings reported by Eni- olorunda et al. [27]. In light of the attitude of women towards the risk factors in pregnancy, about sixty percent of them were worried about the liability of harm to their fetus or newborn baby and the necessity to contact healthcare providers during the pregnancy. However, still, forty percent did not care for harm and refused to see doctors when the pregnancy was normal. Such a finding is probably due to the lower education of surveyed women. Our result disagrees with findings reported elsewhere in Nigeria [27]. Furthermore, 88.4% of women agreed to follow the doctor's advice on nutrition during pregnancy, reflecting high awareness regarding their nutrition. Moreover, about 67.0% of them favored having four children or fewer, reflecting a good attitude. However, long-term development programs such as integrated management of neonate and child health are ideal for enhancing women's education and children's health protection [30]. This study complained about several limitations, including the cross-sectional design. Bias in data collection is liable because of the face-to-face interview. This study also had a small sample selected from a few centers. Therefore, the findings may not be generalizable. Nevertheless, our results may help evaluate the knowledge and attitude of an important segment of Iraqi society. Conclusion In conclusion, the findings of this study showed that pregnant women had adequate knowledge regarding most of the pregnancy-related risk factors, including smoking, obesity, and malnutrition in pregnancy. Forty percent of the women expressed a lack of knowledge of the risks of pregnancy and did not bother to see doctors during pregnancy. Therefore, it is crucial and effective to implement measures to promote appropriate behaviors in women before pregnancy, including assessing pregnant women's knowledge and behaviors about key risk factors. Abbreviation UTI: Urinary Tract Infection; SD: Standard Deviation Declaration Acknowledgment We would like to thank all the participants for their responses and insight during the data collection process. Funding The authors received no financial support for their research, authorship, and/or publication of this article. Availability of data and materials Data will be available by emailing med.badeaa.thamir@uoanbar.edu.iq. Authors’ contributions All authors equally contributed to the concept, design, literature search, data analysis, data acquisition, manuscript writing, editing, and reviewing. All authors have read and approved the final manuscript. Ethics approval and consent to participate We conducted the research following the Declaration of Helsinki. The study protocol was approved by the Ethics committee of the Faculty of Medicine, University of Anbar (2019). All patients gave written informed consent. Consent for publication Not applicable Competing interest The authors declare that they have no competing interests. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author (s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article unless otherwise stated. Author Details 1Department of Family and Community Medicine, Faculty of Medicine, Anbar University, Anbar, Iraq.2Department of Public Health, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey. 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